Provider Demographics
NPI:1245467018
Name:HIGGENBOTHAM, MELISSA MARIE (LPN)
Entity type:Individual
Prefix:MISS
First Name:MELISSA
Middle Name:MARIE
Last Name:HIGGENBOTHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 CATON FARM RD
Mailing Address - Street 2:K
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60403-1386
Mailing Address - Country:US
Mailing Address - Phone:815-609-9081
Mailing Address - Fax:
Practice Address - Street 1:2400 CATON FARM RD
Practice Address - Street 2:K
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1386
Practice Address - Country:US
Practice Address - Phone:815-609-9081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043-081332164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse